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Blog Feature

By: Marietta B. Bibbs, BA, RPSGT, CCSH, FAAST on July 29th, 2021

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Medicare Administrative Contractors (MACs) Increase Focus on Polysomnography Compliance

MAC | Medicare Administrative Contractors

In late 2020, free-standing and hospital-based sleep centers began receiving communications from Medicare Administrative Contractors (MACs) asking for attestations that they were in compliance with their local coverage determinations (LCDs) for polysomnography. LCDs are decisions made by a MAC whether to cover a particular item or service in their jurisdiction (region). MACs are contracted by Medicare to develop LCDs and process Medicare claims. The MAC’s decision is based on whether the service or item is considered reasonable and necessary. The Centers for Medicare & Medicaid Services (CMS) awards geographical jurisdictions to MACS (private health care insurers). National coverage determinations (NCDs) supersede LCDs, but LCDs provide expansion on coverage policies for each jurisdiction. Coverage policies vary among LCDs related to coding, credentialing, diagnostic testing and treatment. This means that Medicare coverage can also vary depending on the geographical location. LCD contractors must follow a specified procedure to issue an LCD, including holding public meetings to discuss a draft LCD, distributing it to medical groups, posting it on their website and offering a 45-day period for public comments (posted on their websites prior to finalizing the LCD).

Although the requirements for polysomnography have been in force since 2010, and there have been frequent revisions each year, hospital-based sleep centers have not always understood or followed the policy of their MAC. This is specifically true for hospitals that are located in a different state than their corporate headquarters. A hospital may not be operating under the MAC for the state where it resides. This has been the focus of increased reviews and requests for attestations from the MACs.

One of the MACs in particular that has been requesting verification reviews is Wisconsin Physicians Service Insurance Corporation (WPS). This issue appears to be more prevalent among hospitals that have maintained a contract with a MAC other than the one that is associated with their geographic state or region. WPS (LCD L36839) covers jurisdictions 5 and 8 (including the states of Iowa, Kansas, Missouri, Nebraska, Indiana and Michigan), but it also covers some providers outside its jurisdiction, which has been its focus for requested attestations.

Hospital-based sleep centers are usually visited by The Joint Commission (TJC) when it surveys the hospital and, in many cases, hospital-based sleep centers have assumed that The Joint Commission Hospital Accreditation Program also covered services for polysomnography; however, in 2017-2018, four MACs (WPS, CGS, Noridian and Palmetto) revised their LCD policies for polysomnography and issued a determination that The Joint Commission Hospital Accreditation was not sufficient for payment of polysomnography services but TJC accrediting a general hospital as an ambulatory care sleep center is sufficient. TJC accreditation for the general hospital does not meet WPS Government Health Administrator’s (GHA) credentialing requirements since it is not the same as a sleep-specific accreditation.

To learn more about the recent MAC updates, read the full article in the 2021 Q2 issue of A2Zzz.

Read the 2021 Q2 Issue